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221. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49433/psn-pdf
     June 23, 2021 - Environmental Safety in the OR February 1, 2004 Linkin DR, Lautenbach E. Environmental Safety in the OR . PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/environmental-safety-or The Case The infection control department of a hospital noticed a marked increase in the rates of post-operative sternal wound inf…

222. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49857/psn-pdf
     March 01, 2019 - Duplicate Insulin Order March 1, 2019 Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/duplicate-insulin-order The Case A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency department (ED) for complaints of letharg…

223. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49869/psn-pdf
     July 02, 2019 - Failure to Rescue the Mother July 2, 2019 Vivero A, Klapper EB, Gregory KD, et al. Failure to Rescue the Mother. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/failure-rescue-mother The Case A 27-year-old woman, G5 P2 A2, was first admitted to the hospital at 25 weeks of pregnancy for vaginal bleeding. An …

224. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49835/psn-pdf
     January 01, 2020 - Don't Pick the PICC July 1, 2018 McGill RL. Don't Pick the PICC. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/dont-pick-picc The Case A 63-year-old man with diabetes mellitus complicated by retinopathy, neuropathy, and nephropathy; glaucoma; and stage IV chronic kidney disease was admitted to the hospita…

225. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49870/psn-pdf
     August 10, 2019 - Anemia and Delayed Colon Cancer Diagnosis August 10, 2019 Pathipati MP, Richter JM. Anemia and Delayed Colon Cancer Diagnosis. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis Case Objectives Describe the initial evaluation for iron deficiency anemia in elderly adults…

226. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49856/psn-pdf
     March 01, 2019 - Premature Extubation March 1, 2019 Sagana R, Hyzy RC. Premature Extubation. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/premature-extubation The Case A 73-year-old woman with a history of carotid artery stenosis was admitted for an elective carotid endarterectomy. The procedure was initially thought to …

227. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49866/psn-pdf
     June 01, 2019 - If You Say So: Taking a Syringe at Face Value in the Operating Room June 1, 2019 Lyndon A, Lim S. If You Say So: Taking a Syringe at Face Value in the Operating Room. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room The Case A 43-year-old woman was admi…

228. Preparing for Health Reform: The Federal Government and the Nursing Workforce | PSNet
     psnet.ahrq.gov/perspective/preparing-health-reform-federal-government-and-nursing-workforce
     September 01, 2012 - Patricia Ebright refers to this as "managing the stack."

229. In Conversation With… Jack Needleman, PhD | PSNet
     psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
     September 01, 2012 - Patricia Ebright refers to this as "managing the stack."

230. Latent Error (or Latent Condition) | PSNet
     psnet.ahrq.gov/glossary/latent-error-or-latent-condition
     September 13, 2021 - Latent Error (or Latent Condition) September 13, 2021 Anonymous (not verified) The terms active and latent as applied to errors were coined by Reason . Latent errors (or latent conditions) refer to less apparent failures of organization or design that contributed to the occurrence of errors or allowed them…

231. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49872/psn-pdf
     August 08, 2019 - Spinal Epidural Abscess August 8, 2019 Lu Y, Salvador D. Spinal Epidural Abscess. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/spinal-epidural-abscess The Case A 30-year-old woman with a history of prior spine surgery presented to the emergency department with a few days of progressive low back pain. She…

232. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49868/psn-pdf
     July 02, 2019 - Delayed Clozapine Prescription in an Elderly Man With Dementia July 2, 2019 Tsourounis C, Ghomeshi KK. Delayed Clozapine Prescription in an Elderly Man With Dementia. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia The Case An 86-year-old man with neurode…

233. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49867/psn-pdf
     July 02, 2019 - Diuretics and Electrolyte Abnormalities July 2, 2019 Dreischulte T. Diuretics and Electrolyte Abnormalities. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/diuretics-and-electrolyte-abnormalities Case Objectives Recognize that thiazide diuretics can lead to serious adverse events. State how commonly used t…

234. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49464/psn-pdf
     December 27, 2020 - Lap Burn October 1, 2004 Ball K. Lap Burn. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/lap-burn The Case A woman was scheduled for an elective diagnostic laparoscopy for dysfunctional uterine bleeding. After accessing the abdomen with the trocar without complication, the surgeon inserted the laparoscope…

235. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49657/psn-pdf
     July 01, 2012 - Not-So-Therapeutic Tap July 1, 2012 Barsuk JH. Not-So-Therapeutic Tap. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/not-so-therapeutic-tap Case Objectives Describe current issues with training clinicians to perform procedures. Understand how simulation can be used to ensure trainees are competent in proc…

236. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49654/psn-pdf
     June 01, 2012 - Transfer Troubles June 1, 2012 Hains IM. Transfer Troubles. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/transfer-troubles Case Objectives Recognize that transfer of patients between hospitals is common. Understand the frequency of errors and adverse events in the transfer of patients between hospitals. …

237. Active Error (or Active Failure) | PSNet
     psnet.ahrq.gov/glossary/active-error-or-active-failure
     September 13, 2021 - Active Error (or Active Failure) September 13, 2021 Anonymous (not verified) The terms active and latent as applied to errors were coined by Reason . Active errors occur at the point of contact between a human and some aspect of a larger system (e.g., a human machine interface). They are generally readily …

238. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49860/psn-pdf
     April 01, 2019 - Hip Fractures in Older Patients: the Case for Geriatrics Comanagement April 1, 2019 Rogers S, Ward D. Hip Fractures in Older Patients: the Case for Geriatrics Comanagement. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/hip-fractures-older-patients-case-geriatrics-comanagement The Case An 82-year-old man …

239. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49662/psn-pdf
     August 01, 2012 - Wrong Turn through Colon: Misplaced PEG August 1, 2012 Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg The Case An 87-year-old man was admitted for congestive heart failure (CHF) exacerbation. In addition, a pa…

240. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49553/psn-pdf
     January 01, 2008 - Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures January 1, 2008 Weinstein MP. Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/contaminated-or-not-guidelines-interpretation-positive-blood-cultures The…